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2 Somatoform Disorders

SOMATOFORM DISORDERS Reporters: Caliolio, Patrizia Angeline H. Carale, Christine H. Catambing, Kimberly Anne Q. Coson, Jan Karmela A. Somatization defined as the transference of mental experiences and states into bodily symptoms. Somatoform Disorders Is the diagnosis given to individuals who present with symptoms suggesting a physical disorder without organic cause or physiologic mechanism (roots are psychological rather than physiological). Characterized by primary gain(anxiety relief) and secondary gains (special attention, relief from responsibilities). Some have coexisting disorders; like panic attacks or agoraphobia (common with somatization disorder), depression (common with pain disorder), OCD (common with body dysmorphic disorder). Patients repeatedly seek medical diagnosis and treatment (even though they have been told that there is no known physiological/organic evidence to explain their symptoms or disability) instead of mental health professionals. THEORIES AND RESEARCH STUDIES Biologic and Genetic Factors Research suggested that these are responsible for the development of somatoform disorder Decreased metabolism in the frontal lobes and in the nondominant hemisphere Faulty perception of somatosensory inputs due to attention and cognitive impairments 10%-20% of the first-degree female relatives Abnormal regulation of cytokines Organ Specificity Theory Lacey, Bateman and Van Lehn They concluded that a person respond to stress primarily with physical manifestations in one specific organ or system, thereby showing susceptibility to the development of a specific disease General Adaptation Syndrome Hans Seyle (1978) An individual who copes with the demands of stress experiences a fight or flight reaction. THREE STAGES: Alarm reaction, resistance and exhaustion Familial or Psychosocial Theory Characteristics of family dynamic relationships, such as parental teaching, parental example and ethnic mores, may influence the development of somatoform disorders. People with somatoform disorders keep stress, anxiety or frustration inside rather than expressing them outwardly which is called internalization. Psychosocial theorists posit that increased incidence of somatization in women may be related to various factors: Boys in US are taught to be stoic causing them to offer few physical complaints. Women seek medical treatment more often than men and are more socially acceptable to do so. Childhood sexual abuse happens frequently more on girls. Women more often receive treatment for psychiatric disorders with strong somatic components such as depression.

Learning Theory A person learns to produce a physiologic response to achieve a reward, attention, or some other reinforcement CULTURAL CONSIDERATIONS Men in India often have dhat which is a hypochondriacal concern about loss of semen. Koro occurs in Southeast Asia and maybe related to dysmorphic disorder. It is characterized by the belief that the penis is shrinking and will disappear into the abdomen causing a man to die. Falling out episodes found in US and Caribbean islands are characterized by a sudden collapse during which the person cannot see or move. Hwa-byung is a Korean folk syndrome attributedto the suppression of anger and includes insomnia, fatigue, panic, indigestion, and generalized aches and pains. Sangue dormido (sleeping blood) occurs in Portuguese Cape Verde Islanders who report pain, numbness, tremors, paralysis, seizures, blindness, heart attacks, and miscarriages. Shenjing shuariuo occurs in China and includes physical and mental fatigue, dizziness, headache, pain, sleep disturbances, memory loss, gastrointestinal problems, and sexual dysfunction. TYPES OF SOMATOFORM DISORDERS

Somatization Disorder Characterized by multiple and often vague physical symptoms associated with psychosocial distress that suggest a physical disorder but have no physical basis. Physical complaints over several years, resulting in treatment being sought or impairment in functioning (occupational, social, others), individual may become extremely dependent in relationship. Symptoms are identified as pain ( at least four different sites), gastro intestinal symptoms (nausea and vomiting , diarrhea), sexual symptoms (irregular menses, erectile or ejaculatory dysfunction) and symptoms suggestive of a neurological condition (paralysis, blindness, deafness).

Pain Disorder Pain without physical basis or pain that greatly exceeds what is expected based on the extent of injury. Disrupt social and occupational functioning ONSET: Fourth or fifth decade of life, common among women Subtypes: 1. Pain disorders Associated with Psychological Factors 2. Pain disorders Associated with Both Psychological factors and General Medical Condition. Essential feature is severe and prolonged pain that causes clinically significant distress or impairment in

2 Somatoform Disorders
social, occupational or other important areas of functioning. Pain is severe enough to warrant medical attention and becomes the patients main focus of attention. Pain involving part of the body; mostly at the back, head, abdomen or chest Location or complaint of the pain does not change, unlike the complaints of a client with somatization disorder. Hypochondriasis Preoccupation with fear of having, or the idea that one has a serious disease, includes misinterpretations of bodily symptoms, preoccupation persists despite medical evaluation and reassurance. Preoccupied by disease conviction (fear that one has a serious disease) and disease phobia (fear of getting a serious disease). Hypervigilance or hypersensitivity of the body and its sensation leads to misinterpretation and overreact to physical signs and symptoms. E.g pimple skin cancer They often seek medical care from numerous sources, when they do not obtain satisfaction from one provider (doctor-shopping). MOST COMMON AGE OF ONSET: Adolescence (16 y/o) may be equally common among men and women Common Symptoms Obsessive and compulsive behavior Major depressive disorder symptoms Suicidal ideation Chronic low self-esteem Feeling self-conscious in social environments; thinking that others notice and mock their perceived defect(s) Repetitive behavior (such as constantly (and heavily) applying make-up; regularly checking appearance in mirrors; see section below for more associated behavior) Seeing slightly varying image of self upon each instance of observing a mirror or reflective surface Perfectionism (undergoing cosmetic surgery) Often use avoidance to cope up with their perceived defect/s. Which may lead to social isolation. Consults cosmetic specialists. - Undifferentiated Somatoform Disorder This diagnosis is used when one or more physical complaints, such as fatigue, pain, or loss of appetite, last 6 months or longer and after appropriate evaluation, cannot be explained by a known general medical condition or the direct effects of a substance. Somatoform disorder, not otherwise specified Diagnosed when somatoform symptoms do not meet the criteria for a any specific somatoform disorder.

Conversion Disorder Involves motor and sensory Anxiety-provoking impulses are converted unconsciously into functional symptoms. The most common somatoform disorder in children and adolescents and young adults. - Key feature is la belle indifference (client has a little or no concern or anxiety about the distressing disorder). 1. Motor symptoms or deficit such as impaired balance, paralysis of an upper or lower extremities, dysphagia and urinary retention 2. Sensory symptoms such as loss of touch or pain sensation, double vision, blindness or hallucinations 3. Seizures or convulsions with voluntary motor and sensory components 4. Mixed presentation (If symptoms is more than 1 category) Function of Conversion Symptoms: 1. Express a forbidden wish of impulse 2. Impose punishment for a forbidden wish or wrongdoing 3. Primary gain relief from an overwhelming life situation 4. Secondary gain allow gratification of dependency Conversion disorder is different with. Malingering production of false or exaggerated physical and psychological symptoms that are CONSIOUSLY motivated by external incentives to avoid unpleasant situation Factitious CONSIOUSLY motivated production of feigning of physical or psychological symptoms to assume the sick role ONSET: Anytime common among adolescent and young adult More frequently in rural population Body Dysmorphic Disorder Having persuasive feeling of ugliness and are preoccupied with an imagined defect in physical appearance or a vastly exaggerated concern about a minimal defect

PSYCHOMATIC DISORDER Psychosomatic or psychophysiological disorder Responses to anxiety are those in which it has been determined that psychological factors contribute to the initiation or exacerbation of physical symptom. E.g asthma, cancer, ulcers, coronary heart disease Malingering Production of false or grossly exaggerated physical or psychological symptoms that are consciously motivated by external incentives to avoid unpleasant situation (e.g avoiding work, obtaining financial compensation, evading criminal persecution). Recurrent headaches and low back pains are frequently chosen as chief complain because it is difficult to disprove.

- Factitious Disorder Consciously motivated production or feigning of physical or psychological symptoms to assume sick role. Emotional care and attention comes with playing the role of the patient. May even inflict injury on themselves to receive attention. Although uncommon, they occur most often in people who are in or familiar with medical professions such as nurses, physicians, medical technicians.

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Munchausen Syndrome by Proxy Usually involves another person, usually the mother, who inflicts illness or injuries on her child to gain attention of the healthcare provider through her childs injury or to become a hero. The most common reasons these parents seek medical attention are for bleeding , seizures, apnea, diarrhea, vomiting, fever and rash. It is a form of child (physical) abuse, and the child must be protected. They are unable to think about or to respond to questions about emotional feelings. They will answer questions about how they feel in terms of physical health or sensations. Clients with hypochondriasis focus on the fear of serious illness rather than the existence of illness.

Sensorium and intellectual process They are alert and oriented. Intellectual functions are unimpaired.

NURSING PROCESS I. Assessment Nurse must investigate physical health status thoroughly to ensure there is no underlying pathology requiring treatment. History Clients may provide a lengthy and detailed account of previous physical problems, numerous diagnostic tests, and maybe some surgical procedures. Clients may express dismay or anger at medical community. General appearance and motor behavior Clients often walk slowly or with unusual gait because of pain or disability caused by symptoms. They may exhibit facial expressions of discomfort or physical distress. They brighten and look much better when assessment begins because of the undivided attention of the nurse. They may describe complaints in colorful exaggerated terms but lack specific information. They are firmly convinced their problem is entirely physical and often believe that no one understands. -

Judgment and insight They have little or no insight into their behavior.

Self concept They focus on the physical part of themselves. They are unlikely to think about personal characteristics or strengthen and are uncomfortable when asked to do so. They have low self esteem and seem to deal with it by totally focusing on physical concerns. They lack confidence, have little success in work situations and have difficulty managing daily life issues, which they relate solely to their physical status. Roles and relationship They are unlikely to be employed or often lose jobs because of excessive absenteeism or inability to perform work or may quit work voluntarily because of poor physical health. Difficulty fulfilling family roles because of constant feeling of wanting to seek medical treatment They may have few friends and spend little time in social activities. They may decline to see friends or go out socially. For fear they may become desperately ill. Most socialization occurs with the health care community. They may report lack of family support. Home life is often chaotic or unpredictable. Physiologic and self care concerns

Mood and affect Mood is often labile, shifting from seeming depressed and sad when describing physical problems to looking bright and excited when talking about how they had to go the hospital in the middle of the night by ambulance. Emotions are often exaggerated, as are reports of physical symptoms. Clients describing a series of personal crises related to their physical health may appear pleased rather than distressed about their situation.

Thought process and content Clients do not experience disordered thought processes. The content of their thinking is primarily about often exaggerated physical concerns.

Sleep pattern disturbances Lack basic nutrition

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Get no exercise Maybe taking multiple prescriptions for pain or other complaints. PHYSICAL SYMPTOMS BBD is difficult to assess, because such clients are ashamed of their or have poor insight to reveal symptoms. Clients who present with pain are also difficult to assess because, in some cases, the pain may exist without apparent cause or it may be perpetuated by factors that are remote from the initial cause Clients denial of emotional problems, inability to express self and reliance on meds makes it difficult for assessment ASSESSMENT TOOLS OR SCREENING TESTS: 1. Body Dysmorphic Disorder Questionnaire is a brief, simple self-report screening measure that follows the DSM-IV criteria for BDD. 2. Body Dysmorphic Disorder Examination is developed by Rosen and Reiter (1996), a 33-item semi-structured clinical interview that yields criteria for BDD diagnosis as well as a severity score. 3. Wong- Baker Face Pain Scale 4. Numeric Pain Scale 5. Brief Headache Screen - a method for rapid screening for migraine, daily headache syndromes and medication overuse Nursing Diagnosis Ineffective coping Ineffective denial Impaired social interaction Anxiety Disturbed sleep pattern Fatigue Pain Project SMART Impaired Physical Mobility (Stress Management and relaxation Techniques) Activity Intolerance Activity Intolerance r/t increased complaints secondary to hypochondriasis physical Helps client with somatoform disorders cope with stressful life events by teaching the 6 characteristics of stressresistant persons: Use of reasonable mastery skills Tricyclic antidepressants e.g Amitriptyline (Elavil), Protriptyline (Vivactil) Nursing Interventions Build a trust relationship Avoid appearing judgmental (be aware of responses) Interactive therapy - (individual, group, insightoriented and cognitive therapy): encourages client to express feelings Behavioral interventions - mode of treatment by means of systematic manipulation of the environment and variables that are functionally related to the behavior Fatigue r/t extreme stress secondary to imagined defect in appearance Impaired physical mobility r/t leg pain secondary to conversion disorder

Planning The client will report a reduction in symptoms of activity intolerance secondary to multiple somatic complaints of pain. The client will verbalize fewer somatic complaints as social interactions improve. The client will appearance. demonstrate acceptance of

The client will demonstrate measures to increase physical mobility.

Medication Management Anxiolytics for treatment of anxiety SSRI (Serotonin Reuptake Inhibitors) e.g. fluoxetine (prozac), sertraline (Zoloft)

Impaired Social Interaction r/t effects of multiple somatic complaints that interfere with relationships

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Commitment to meaningful project Making choices of wise some Nurse should help patients learn and practice these techniques, emphasizing that their effectiveness usually improves with routine use. These will focus on helping them manage or diminish the intensity of symptoms.

lifestyle -

Seeking out of social support Maintenance of a sense of humor Demonstration of concern for the welfare of others Advocates gradual reduction of dietary stimulants, use of relaxation exercises and stress inoculation procedures

2. Problem focused coping strategiesWhich help to resolve or change a clients behavior or situation or manage life stressors It includes Learning problem solving methods, applying the process to identify problems and role playing interactions. Nurse can help client to plan social contact with others, can role play what to talk about with each other and improve clients confidence in making relationships. Nurse can also help identify stressful life situations and plan strategies to deal with them.

Provide health teaching 1. Nurse must help patient establish a daily routine with improved health behaviors. 2. Adequate nutritional intake, improved sleeping pattern, realistic balance of activity and rest are areas that may need assistance. 3. The nurse should expect resistance, protests that client is not feeling well enough to do such things. 4. The nurse should validate the clients feelings while encouraging her or him to participate in activities. 5. Nurse should not attempt to confront clients about somatic symptoms or attempt to tell them that these symptoms are not real. Assist client to express emotions 1. Teaching about relationship between stress and physical symptoms VI. 2. A journal may help clients see when physical symptoms seemed worse or better and what factors may affect perception. Limiting the time that clients can focus on physical complaints alone may be necessary. Encourage them to focus on emotional feelings is important. Nurse should provide attention and positive feedback for efforts to identify and discuss feelings. III. IV. V. II. Evaluation

If treatment is effective client should make fewer visits to physicians, use less medications and more positive coping techniques and increase functional abilities. Patient would also have improved family and social relationship. Relief of symptoms Effective coping skills are exhibited Clients are able to identify anxiety-producing stressors and demonstrate insight into their specific disorder Follow-up care

Points to consider when working with clients with somatoform disorder: Carefully assess clients physical complaints. Validate the clients feelings while trying to engage him or her in treatment. Remember that the somatic complaints are not under the clients voluntary control. Sources: Sheila L. Videbeck, Psychiatric-Mental Health Nursing, 5th Ed. Louise Rebrace Shives, Psychiatric-Mental Health Nursing, 7th Ed. B.J. Saadock & V.A. Sadock, Comprehensive Textbook of Psychiatry, Vol. 1 8th Ed.

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Teaching coping strategies 1. Emotion focused coping strategies which help clients relax and reduce feelings of stress it includes Progressive relaxation, deep breathing, guided imagery and distractions such as music